NPIMap

Organization Active NPI

Samuel U. Rodgers Health Center, Inc.

Doing business as Samuel U. Rodgers Health Center Northland Family Medicine

  • Federally Qualified Health Center (FQHC)
  • Kansas City, MO
National Provider Identifier
1386195113
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SAMUEL U. RODGERS HEALTH CENTER, INC.
Doing business as
Samuel U. Rodgers Health Center Northland Family Medicine
Practice address
5330 N Oak Trfy Ste 104
Kansas City, MO 64118-4600
Phone
(816) 889-1950
Fax
(816) 499-8101
NPI assigned
Oct 17, 2016
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Hilda Fuentes, MPA
Title
President & Chief Executive Officer
Phone
(816) 889-4600

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X MO Primary

Addresses

Primary practice location

5330 N Oak Trfy Ste 104
Kansas City, MO 64118-4600

Mailing address

825 Euclid Ave
Kansas City, MO 64124-2323
Phone (816) 474-4920

Other names 1

  • Samuel U. Rodgers Health Center Northland Family Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031105000813 MO Part B Supplier - Clinic/Group Practice 9739092826 Receives reassigned benefits from 81 practitioners
11 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Blue Springs, MO; Kansas City, MO; Liberty, MO
O20170905002968 MO Part A Provider - Federally Qualified Health Center (FQHC) 9739092826 Practice locations: Kansas City, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386195113. Details of each certification follow.

Federally qualified health center certification: CCN 261141

Legal name
SAMUEL U RODGERS HEALTH CENTER INC
Doing business as
SAMUEL U. RODGERS HEALTH CENTER NORTHLAND FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 5, 2017
Last certification
Sep 5, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
5330 N Oak Trfy
Ste 203
Kansas City, MO 64118-4600

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Samuel U Rodgers Commun11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Monique Jones Individual Corporate OfficerDirector of Risk and Compliance Nov 12, 2024
Corporate DirectorDirector of Risk and Compliance Nov 12, 2024
Robert Theis Individual Corporate OfficerCeo Feb 2, 2009
W-2 Managing EmployeeCeo Feb 2, 2009
Christopher Walker Individual Corporate OfficerCfo Nov 12, 2024
W-2 Managing EmployeeCfo Nov 12, 2024
Elizabeth Bordenave Individual Corporate OfficerBoard Chair Nov 12, 2024

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1476662400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1386195113",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "825 EUCLID AVE",
            "city": "KANSAS CITY",
            "state": "MO",
            "postal_code": "641242323",
            "telephone_number": "816-474-4920",
            "fax_number": "816-889-1845"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5330 N OAK TRFY STE 104",
            "city": "KANSAS CITY",
            "state": "MO",
            "postal_code": "641184600",
            "telephone_number": "816-889-1950",
            "fax_number": "816-499-8101"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAMUEL U. RODGERS HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-17",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "FUENTES",
        "authorized_official_first_name": "HILDA",
        "authorized_official_title_or_position": "PRESIDENT & CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "816-889-4600",
        "authorized_official_credential": "MPA"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MO",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Samuel U. Rodgers Health Center Northland Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kansas City, MO

Sources for this page

Verify at the official NPI Registry.